Hospitalization for severe malnutrition among HIV-infected children starting antiretroviral therapy

Abstract

Objective: To describe early hospitalization for severe malnutrition in HIV-infected children initiating antiretroviral therapy (ART).

Design: Randomized trial of induction-maintenance and monitoring strategies in HIV-infected children.

Setting: Three tertiary hospitals in Uganda and one in Zimbabwe.

Participants: 1207 HIV-infected children, median age 6 years (range, 3 months to 17 years).

Intervention: Abacavir, lamivudine and nevirapine or efavirenz were given; children in induction-maintenance arms also received zidovudine to week 36. Pre-ART inpatient/outpatient nutritional rehabilitation for children with baseline severe malnutrition.

Main outcome measures: Hospitalization for severe malnutrition and change in CD4 cell percentage by week 12 after ART. Mortality and change in weight-for-age Z-score (WAZ) by week 24 after ART.

Results: Thirty-nine of 1207 (3.2%) children were hospitalized for severe malnutrition (20 with oedema), median 28 days [interquartile range (IQR) 14, 36] after ART for marasmus and 26 days (IQR 14, 56) after ART for kwashiorkor. Hospitalized children had lower baseline and greater 24-week rise in WAZ than non-hospitalized children (P less than 0.001). Twenty-nine of 39 (74%) children admitted for severe malnutrition had underlying infections. Of 220 children with advanced disease (baseline WAZ and CD4 cell Z-scores both less than -3), 7.3% [95% confidence interval (CI) 3.8, 10.7] developed kwashiorkor and 3.6% (95% CI 1.2, 6.1) developed marasmus by week 12. CD4 cell percentage rise was similar among groups (P = 0.37). Twenty-four-week mortality was 32, 20 and 1.7% among children hospitalized with marasmus, kwashiorkor and not hospitalized, respectively, (P less than 0.001).

Conclusion: One in nine children with advanced HIV required early hospitalization for severe malnutrition after ART, with a 15-fold increase in 6-month mortality compared with non-hospitalized children. Integration of HIV/malnutrition services and further research to determine optimal ART timing, role of supplementary feeding and antimicrobial prophylaxis are urgently required.

Citation

Prendergast, A.; Bwakura-Dangarembizi, M.Fb; Cook, A.D.; Bakeera-Kitaka, S.; Natukunda, E.; Nahirya-Ntege, P.; Nathoo, K.Jb; Karungi, C.; Lutaakome, J.; Kekitiinwa, A.; Gibb, D.Ma. Hospitalization for severe malnutrition among HIV-infected children starting antiretroviral therapy. AIDS (2011) 25 (7) 951-956. [DOI: 10.1097/QAD.0b013e328345e56b]

Hospitalization for severe malnutrition among HIV-infected children starting antiretroviral therapy

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